Axial skeleton

Researches have shown that 75-80% of athlete’s problems were spinal.

Functional anatomy

The disc

Each disc has a central nucleus pulposus, a surrounding annulus fibrosus and the limiting cartilage end plates.

Nucleus pulposus

The nucleus pulposus is a soft hydrophilic substance contained within the centre of the disc.

Annulus fibrosus

The annulus is at its weakest in the posterolateral region, where the cellular structure is less well organized. Therefore, the nucleus pulposus most commonly herniates in a posterior or posterolateral direction, and less in a lateral direction, towards the spinal canal.

Cartilage end plate

This represents the anatomical limit of the disc. The annular epiphyses of the vertebral body develop in marginal part of this thin and plate. Stress changes across this area, in the teenager, produce pain. Rarely, trauma may produce an avulsion of the disc’s bony attachment, creating a posterior marginal node, or limbus fracture… in teenagers there is a small avulsion fracture of the vertebral end plate that can protrude into the spinal canal.

Ligaments

1)      The anterior longitudinal ligament – supports the anterior aspect of the vertebral bodies, including the discs

2)      The posterior longitudinal ligament – attached to the posterior aspect of vertebral bodies, but creates the anterior wall of the spinal canal. It is not strong as the anterior ligament

3)      The ligamentum flavum – forms the posterior aspect of the spinal canal. It is an elastic ligament that helps maintain the upright posture and the return of the spinal column to its erect position after bending

4)      The supraspinous ligament – runs over the tips of the spines and connects with the interspinous ligament that joins the spinous processes. The ligaments are strongest at the lumbar level

Facet joints

The vertebral arches are joined at their bases by the synovial, zygapophysical joints; whose shape will control the rangeof movement between the concomitant vertebrae. The thoracic vertebrae favour lateral bending and rotation, whilst the lumbar facets favour flexion, extension, and lateral bending;at the higher lumbar levels.

Innervation

The innervation of the disc, posterior longitudinal ligament, periosteum, venuos sinuses and spinal dura is from the sinuvertebral nerve and contains spinal and sympathetic branches.

Spinal cord and meninges

Spinal cord ends at the level of L1/2. The nerves that exit below this level of S2, the cauda equina, and the filum terminale connects the meninges to their eventual insertion.

Function of the vertebral column

The major function of the vertebral column is to support and protect the spinal cord from physical trauma. Less energy is required to maintain posture because spinal muscles support vertebral column. Core stability exercises and skills use this principle for functional muscle control of the back.

In the lumbar spine the movements of flexion, extension and side flexion compress the disc on one edge and stretch the other, and this movement pushes the nucleus pulposus towards the stretched surface so that, in flexion, the nucleus pulposus will move posteriorly, towards the weakest area of annulus.

Flexion of the spine is limited by elasticity of the ligamentum flavum, the inter-  and supraspinous ligaments, the posterior part of the disc and the posterior longitudinal ligament.

Vertebral column is more stabile in extension position, when the facet joints interlock. Core stability techniques are designed to train these stabilizing muscles, both local and global, to reduce excessive lumbar segmental instability.

Clinical application

Reffered pain

Damage to the lumbar spine may cause localized pain, or reffered pain to the groin, buttock, thigh, shin, calf, ankle or foot; with or without accompanying local back pain. Upper limb pain examinations should exclude referral from the cervical spine.

Leg pain

There are certain clues that suggest pain is referred from the nerve root or dura:

a)      night pain wakes the athlete from sleep, as opposed to pain created by the movement of turning in bed. The former suggests that movement is not cause

b)      “Pins and needles” or paraesthaesia in the leg

c)      The pain may be worse on caughing or blowing the nose

d)     Radiation of pain into the foot is usually from the nerve, not facet or sacroiliac joint.

e)      Descriptions of pain include hyperaesthesia, burning, lancinating, electric shock, water- flowing sensations in the limb. However, burning, relentless pain in a stocking distribution is more possibility of regional pain syndrome

f)       The intensity of pain description  on VAS( visual analogue pain scale) -  8-10

Bone pain

-          tumours and infections of the spine give a history of continuos pain, usually with an insidious onset, that may or may not be affected by biomechanical movement

-          locomotor problems are affected by normal biomechanical movement patterns, which alter the pain intensity, and may at times be pain-free

Non-mechanical back pain

One of the following:

a)      night pain, without movement, that wakes an athlete

b)      unremitting pain

c)      pain not made worse by movement

d)     loss of weight

e)      systemically unwell

f)       raised temperature

g)      generalized aches and pains; myalgia

h)      other joints are painful

i)        flitting joint pains; arthralgia

j)        dysuria

k)      eye symptoms: iritis, uveitis, conjunctivitis

l)        urethral discharge, sexually transmited disease, human immunodeficiency virus(HIV)

m)    skin problems – rash, psoriasis

n)      known primary carcinoma

o)      hypo/hyperthyroidism

p)      family history of spondylarthropathy

Mechanical back pain

There is no black&white method. Common biomechanical methods problems include:

a)      disc herniation, annular tears, and nucleus pulposus pressure on the annulus

b)      facet joint arthrosis, or arthritis

c)      part interarticularis fractures

d)     wedge fractures of the vertebral body

e)      Scheuermann’s vertebral ring epiphysitis

f)       Sacroiliac dysfunction

g)      Ligamentous strain

h)      Interspinous impingement

i)        Spinal stenosis and lateral canal entrapment

j)        Myofascial and muscle pain

Coccygeal pain

Fall on the base of the spine may damage sacrococcygeal ligaments. Sitting and full flexion are painful. In this case steroid injections are used to decrease the pain.

Management of back pain

History – divided into flexion- oriented, extension-oriented and mixed

Localized muscle injuries

Nerve root damage

The distribution of symptoms indicates the level. For example, groin - T12/L1; front of the thigh - L2/L3;front of the thigh, knee and anterior shin - L3/4; back of leg to calf, shin or foot, L4/5 S1; sole of foot, S1; perineal or perianal S3/4. Signs of nerve involvement of the sciatic nerve are straight leg raise reduced, Laseque’s test positive.

Lumbar spine nerve root signs

L1/2  Weak psoas

L3/4  Weak quadriceps and diminished or absent knee jerk

L4     Weak tibialis anterior and diminished or absent knee jerk

L5     Weak extensor hallucis longus, extensor digitorum longus, extensor digitorum brevis, peroneals. Peroneal weakness can present with either L4 or L5 root involvement

S1      Weak calf, hamstring and diminished or absent ankle jerk

S1/2   Weak gluteals

S3/4    Loss of control of the anal sphincter of mictricution. Loss of perineal sensation and reduced or absent anal/perineal reflex

Correcting the posture

Rounded back - Kyphosis

The pain is worse bending over, sitting, driving and getting out of chair, when the back feels a little stuck and is eased by leaning backwards. The pain is reduced when lying face down, and arching backward. More lumbar lordosis is required.

To increase extension:

a)      sleep on hard mattress/floor/futon

b)      sit on a low chair, with a huge desk, and raise the computer screen

c)      sit with one foot drawn under the chair, or the knee pointing to the ground

d)     use a wedge cushion on the chair, kneel on chairs, or tilt the front on the chairs downwards

e)      drive sitting upright and closer to the steering wheel, with the bent arms

f)       stand with the centre of gravity towards the balls of feet. Sit and stand tall, using the core stabilizers

g)      if slumping in an easy chair, slump with the lumbar spine in extension

h)      When leaning over a solid object, stand with legs wide apart, to lose height, brace the pelvis against the solid object and maintain the forward lean, with an extended spine

i)        Lock the back in extension whilst bending or lifting, and splint the spine with a core stability technique

Neutral position

The neutral position is the ideal posture but varies between individuals, so the following description has degrees of tolerance. The athlete should stand with the weight balanced over the middle of the feet, with a slight lordosis, stomach muscles gently tightened and braced by multifidus. The chin and head are drawn back. Arms and scapulae hang naturally, without tension.

Hollowed(sway) back - Lordosis

To decrease extension:

a)      sleep on a soft mattress

b)      instead of standing, reduce the limbar lordosis by perching or half sitting on the edge of  a table. Use a bar stool, even at the kitchen sink. Use a shooting stick without sightseeing

c)      Stand with one foot resting on an object raised 15-20cm

d)     Stand with the body’s centre of gravity towards the heels

e)      Use a core stability technique to lock the back in neutral position when bending or lifting

Bending

All types of bending should go from the pelvis. Bend your pelvis and make a straight line in your back. Do not bend only neck or upper back. If necessary, when you do something better stand closer to an object and make normal straight back position.

Training with back-problems

a)      Weights – the back must be stabilized to lock into neutral, preferably extension, even when sitting. The moment this back position cannot be held, the exercise should be stopped. If the back has to be bent aid the exercise, then the target muscles that are being trained will have fatiqued sufficiently for the back muscles to be recruited in to help with the exercise. If lumbar extension cannot be held, then weight is too heavy, or wrong technical position

b)      Sit- ups – neutral sit-ups should be used, sit- ups with twist can cause problems

c)      Swimming – produces extension and thus is excellent for flexion- orientated problems but poor for extension-oriented problems, which tolerate backstroke better. Running in a floatation jacket may be tolerated

d)     Cycling – good for extension oriented problems, but patients have to sit upright with raised handlebars for flexion-orientated problems, the frame may have to be lengthened

e)      Running – should be avoided until symptoms disappear, as the impact compresses the disc and facet joints. On resuming exercise it is better if the runner tries to run tall and core stabilize the pelvis and back

Home and workplace advices

a)      Do not twist telephone between shoulder and head, it twists neck sideways; use earpiece or headset

b)      Adjust computer and chair to correct height, or problems will occur in the future with your back. Wear computer glasses – they should be adjusted to focus on the screen

c)      The computer screen should be 15-30 degrees below eye level, and the keyboard and mouse should be operated with relaxed shoulders and bent elbows. If they are positioned to one side, it will create dorsal problems

d)     Office chairs should be fully adjustable – tilt to the seat, the lumbar curve, the back and height

e)      A kneel-on chair, seat wedge and lumbar rolls will help pain produced by sitting with the rounded back

f)       Lumbar supports in cars are useless, unless they adjust up and down to fith the lumbar curve of the patient in question. Car seats often leave arms to far from steering. Those with back problems need to sit nearer the steering wheel, with bent arms, in order to take the tension out of the back

g)      In the home, sit to the front of the chair, or sideways on a sofa, resting the back against the arm and pointing knee towards the floor, this will tilt the pelvis and increase lordosis in a comfortable, relaxed way

h)      Gardening can cause problems. It is important to learn to bend with a neutral to lordotic back, buttocks out, hips and knees bent, and weight over the middle of the feet

i)        Plan 5-10 minutes of bending jobs around the house and garden, and alternate 5-10 minutes with standing and reaching jobs

j)        Try vacuuming the side, and slightly bending the hips

k)      Standing half bent over a sink, ironing board, etc. is  a killer for the back. Stand with wide apart legs drops the height without bending the back or straining the knees. Leaning the front of the thighs into the side of the sink enables a neutral back position to be held whilst reaching into the sink

l)        Use the “bottom out” position for all half bent positions

 

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English